Approach to Empyema in children

1. Empyema in children
Gopakumar Hariharan
Senior Registrar, General Paediatrics
Royal Hobart Hospital, Tasmania

2. Parapneumonic effusion and empyma in
children
 Case scenario
 Pathogenesis
 Clinical features
 Various management strategies
 Guidelines on management

3. Case scenario
 7 year old boy referred
from regional hospital
with a diagnosis of left
sided pneumonia
 Unwell since one week
with fever , cough and
breathing difficulty prior
to admission
 Past history of
pneumococcal
pneumonia in 2009 Ceftriaxone and Flucloxacillin and
supportive measures

4. One week post admission
4 days after
admission 7th day post admission
Tachypneic and febrile , but no
oxygen requirement

5. Chest tube drainage
 Continued respiratory
distress
 Chest drain – Not
suggestive of empyema –
No leukocytes / growth
 No significant drainage
and he continued to have
low grade fever
 Repeat ultrasound
showed fluid collection
and tube to be in good
position
 Repeated tube aspiration
done – drained around
200 ml and then needed
aspiration a few more
times
9 days post admission

6. Tube drainage
 Stopped draining again . Repeat ultrasound showed
suspicion of loculation
 Urokinase given and further aspiration done . There
was some drainage
 Always serous fluid , never pus
 Continued to have low grade fever but clinically well
 No significant drainage - Removed tube( total of 8
days insertion)

7. After chest tube removal
 Continued fever
 CRP – 56 (5 days back–
45 )
 Respiratory swab -
Positive RSV
 Blood culture – No
growth
 Ultrasound abdomen for
subphrenic abscess –
normal
2 days post removal

8. Ongoing management
 Tazocin and Azithromycin ( ID consult )
 VATS procedure considered – Not started as afebrile
and had clinical improvement
 Continued on Augmentin
 Follow up

9. Immunological tests
 CD3 ( Mature T cells ) – 2.4 ( 0.7 – 2.0 )
 CD 4 ( helper and inducer cells ) – 1.3 ( 0.4 – 1.1 )
 CD 8 ( suppressor / cytotoxic T cells ) – 0.9 / micro L ( 0..3 –
0.7 )
 CD 19 ( Pan B cells ) – 0.4 / microL ( 0.1 – 0.4 )
 CD3- / CD 16+56+ - 0.5 / microL ( 0.1 – 0.5 )
 Normal HLA DR expression
 Memory B cell analysis – Normal
 IgG – 11.3 g/L ( 5.4 – 18.2 )
 IgA – 2.23 g / L ( 0.21 – 2.90 )
 IgM – 1.05 g / L ( 0.47 – 2.40 )
 C3 – 1.63 g / L ( 0.81 – 1.72 )
 C4 – 0.27 g / L ( 0.14 – 0.45 )
Severe streptococcal pneumonia infection
Past history of strep Pneumonia
Previous vaccination with pneumococcal
vaccine

10. Evolution to Empyma
Inflammation of
pleura
subsequent leakage of
proteins, fluid . Low WBC
Deposition of fibrin –
Septation and
loculation – increase in
WBC
Fibroblast infiltration + thick
exudates and heavy sediment
– prevent lung expansion (
trapped lungs ) – potential
space for infections
Empyema – Grossly purulent fluid
in the pleural cavity
Fibrin deposition in pleura and
fomation of septation
Simple
parapneumoni
c effusion
Complicated
parapneumoni
c effusion
Exudative stage
Fibrinopurulent
stage
Organisational
stage
Hamm H, Light RW. Parapneumonic effusion and empyema. Eur Respir

11. Epidemiology and organism profile
.
Childhood empyema occurs in 0.7% of pneumonias in Australia
Strachan R, Jaffé A; Australian Research Network in Empyema. Assessment of the burden of paediatric empyema in
Australia. J Paediatr Child Health 2009;45:431–6. doi:10.1111/j.1440-1754.2009.01533.x PMID:19722296
Organism profile and immunization
• PCV 7 ( 2001 ) – reduced invasive pneumococcal infection
• However , concomitant increase in empyema cases ( 90% of cases
caused by bacterial serotypes 1 , 3 and 19A not included in the 7
valent vaccine ) . More virulent strains
Byington CL, Korgenski K, Daly J, Ampofo K, Pavia A, Mason EO. Impact of the pneumococcal
conjugate vaccine on pneumococcal parapneumonic empyema. Pediatr Infect Dis J 2006;25:250–
4. doi:10.1097/01.inf.0000202137.37642.ab PMID:16511389
In July 2011 the PCV7 was replaced by a 13-valent conjugate vaccine

15. Children with pneumonia presenting with prolonged fever, tachypnoea, pain on
abdominal palpation and high serum C-reactive protein levels are at risk for
parapneumonic empyema.
Fever pattern
CRP
pattern

16. Goals of therapy
Resolution of
pleural cavity
Resolve
symptom
s and
prevent
progressi
on of
empyma
Sterilization of
pleural fluid
Reexpan
sion of
lungs

17. Initial management
 Supplemental oxygen if saturations below 93%.
 Fluid management , antipyretics
 Adequate analgesia – to allow pain free respiration
and mobilisation
 Intravenous antibiotics – in all children with
parapneumonic effusion
No role for chest physiotherapy apart from early mobilisation and
encouragement of deep breathing and coughing, particularly after
surgical intervention or tube drainage

18. Conservative management
Small effusion – ( <10 mm on lateral decubitus
radiograph or opacifying less than one-fourth of the
hemithorax ) - broad-spectrum oral antibiotics and
close observation with chest radiographs on an
outpatient basis
Antibiotics alone or antibiotics +/- simple drainage

19. Thoracocentesis
+ Antibiotics for
48 hours +
continued
observation
Moderate amount of free fluid
on chest radiograph and
ultrasonography
Chest tube/
fibrinolytics/ VATS
Continue
antibiotics
Clinical
improvement
Persistence of fluid
collection and fever
and evidence of
loculation on USG
Antibiotics found to be effective
In about half of such patients

20. Choice of Antibiotics
 Recommendations not evidence based
 Initial treatment should guided by local antibiotic
policy
 Cefuroxime with dicloxacillin/chloramphenicol where
equal efficacy was found ( Randomized )
( Palacios GC, Gonzalez SN, Perez FL, et al. Cefuroxime vs a dicloxacillin/ chloramphenicol combination for
the treatment of parapneumonic pleural effusion and empyema in children. Pulm Pharmacol Ther 2002;15:17–
23 )
 Cefuroxime
 Co-amoxiclav
 Penicillin and flucloxacillin
 Amoxicillin and flucloxacillin
 Clindamycin
In community
acquired infection

21. Role of ultrasonography
 Bedside tool
 Confirm fluid presence
 Stages complexity
 Assess volume
 Guide drainage site
Ultrasound was demonstrated to be of equal clinical
value compared to CT scanning in detecting
parapneumonic effusions
Kurian J, Levin TL, Han BK, Taragin BH, Weinstein S (2009)
Comparison of ultrasound and CT in the evaluation of pneumonia
complicated by parapneumonic effusion in children. JR 193:1648–
1654

22. CT scan detects more parenchymal abnormalities than chest
radiography.
However, the additional information does not alter management
and is
unable to predict clinical outcome.
No role for the routine use of CT scanning in children if treated
with urokinase and percutaneous chest drain.
Expose children to unnecessary radiation ( 20 to 400 CXR
radiation)
CostlyCT scan ( To exclude pulmonary abscess or other pus collection )
• Persistent fever
• A rise in WBC and C-reactive protein

23. Thoracocentesis ( moderate to large
effusions )
Adegboye VO, Falade A, Osinusi K, Obajimi MO. Reexpansion pulmonary oedema
as a complication of pleural drainage. Niger Postgrad Med J 2002;9:214–20
 Reaccumulation of fluid - after the initial thoracentesis – insert
chest tube
 Repeated thoracentesis is not recommended ( BTS )
Aspiration quantitity - limited to 10 to 20 mL/kg -
Rapid removal of large amounts of pleural fluid -
pulmonary edema - worsening of respiratory
status.

24. Pleural fluid analysis
 Gram stain and bacterial culture
 Differential cell count
Biochemical analysis of pleural fluid is unnecessary in the
management of uncomplicated parapneumonic effusions/
empyema ( BTS )
Modified by prior antibiotic therapy
Additional techniques
• Enrichment culture for aerobic and anaerobic organisms,
• Serum or urine latex agglutination tests for detection of pneumococcal
antigen
• Specific or broad range polymerase chain reaction (PCR)
Eastham KM, Freeman R, Clark J, et al. Clinical features, aetiology and outcome of empyema in
the North East of England. Thorax 2004;59:522–5.

25. Management of loculated or organized
pleural effusion
 Fibrinolytic therapy
 Videoassisted thoracoscopic surgery
 Minithoracotomy
 Decortication
A chest drain is left in place after each of these
procedures for continued drainage of fluid or pus.
No consensus on the role of medical versus surgical
management

26. Large amounts of
free flowing
pleural fluid
Compromised
pulmonary
function (eg,
severe
hypoxemia,
hypercapnia)
Evidence of
fibrinopurulent effusions
(eg, pH <7.0, glucose
<40 mg/dL [2.22
mmol.L , LDH more
than 1000 IU , Positive
gram stain , Frank pus
Failure to respond
in 48 to 72 hours of
antibiotic therapy
Indications
For chest tube
drainage

27. Choice of chest tubes
 Smaller catheters (8–12 FG) - as effective as larger
bore tubes.
(Clementsen P, Evald T, Grode G, et al. Treatment of malignant pleural effusion: pleurodesis using a
small bore catheter. A prospective randomized study. Respir Med 1998;92:593–6 )
Advantages
 More comfortable
 Better patient mobility
 Shorter hospital stay
Ultrasonographically guided insertion of small pigtail catheters for treatment of
early loculated empyema has been well studied in children and found to be
effective.
Pierrepoint MJ, Evans A, Morris SJ, et al. Pigtail catheter in the treatment of empyema
thoracis. Arch Dis Child 2002;87:331–2
Pigtail catheter -
Seldinger technique

28. Fibrinolytic agents
 Urokinase – only agent studied in a controlled fashion in
children ( recommended by the BTS )
Thomson AH, Hull J, Kumar MR, et al. Randomised trial of intrapleural urokinase in the
treatment of childhood empyema. Thorax 2002;57:343–7 )
 In one retrospective case series, thoracostomy tube drainage
was increased with Alteplase compared to urokinase
 The choice of agent depends upon availability, with urokinase
being preferred if it is available, followed by alteplase
(recombinant tissue plasminogen activator) and streptokinase.
Intrapleural fibrinolytics shorten hospital stay and are recommended for any
complicated parapneumonic effusion (thick fluid with loculations) or
empyema (overt pus)

29. Surgical management
Failure of chest tube drainage, antibiotics, and
fibrinolytics should prompt early discussion with a
thoracic surgeon
Early operative management
• Reduced duration of chest tube (4.4 versus 10.6
days)
• Reduced Hospital stay (10.8 versus 20 versus )
• Reduced Antibiotic therapy duration ( 12.8 versus
21.3 versus )
• Reduced Mortality (0 versus 3.3 versus 0 )
• Low reintervention rate ( 2.5% versus 23.5% )

30. Video assisted thoracoscopic surgery
VATS - achieves debridement of fibrinous pyogenic
material, breakdown of loculations, and drainage of
pus from the pleural cavity under direct vision. It
leaves three small scars.
The use of early VATS (<48
hours after admission) versus
late VATS (>48 hours after
admission) significantly
decreased the length of
hospitalization
Karen D. Schultz, Leland L. Fan, Jay Pinsky, Lyssa
Ochoa, E. O'Brian Smith, SheldonL. Kaplan and Mary L
. The Changing Face of Pleural Empyemas in
Children: Epidemiology andManagement.
BrandtPediatrics 2004;113;1735

31. VATS versus thoracostomy
Children in the VATS group had shorter length of
hospital stay and duration of chest tube drainage (
small randomized controlled trial )

32. VATS versus conventional medical therapy (
with or without fibrinolysis )
Increased hospital stay and duration of chest tube
drainage were noted in the group treated with medical
therapy.

33. VATS with medical therapy with fibrinolysis
VATS
• Shorter hospital stay
• Improved drainage
• Enhances chance of full expansion of collapsed lungs
Wait MA, Sharma S, Hohn J, et al. A randomised trial of empyema therapy. Chest
1997;111:1548–51.
• High failure rate in late presenting cases
• Not suitable for advanced organised empyema.
Klena JW, Cameron BH, Langer JC, et al. Timing of video-assisted thoracoscopic debridement
for pediatric empyema. J Am Coll Surg 1998;187:404–8.
Harder to perform in apatient who has been receiving intrapleural
urokinase as theloculations become very adhesive, although this
may be due to the delay rather than the urokinase itself.
Jaffe´ A, Cohen G. Thoracic empyema. Arch Dis Child 2003;88:839–41

34. VATS versus conventional thoracotomy
Children in the VATS group had
• Shorter duration of analgesia use
• Shorter postoperative length of hospital stay,
• Shorter time to normothermia, and
• Shorter duration of postoperative chest drains,
as well as Better cosmesis ( Non randomized
study )

35. Other surgical options
Mini-thoracotomy achieves debridement and
evacuation in a similar manner to VATS but it is an
open procedure leaving a small linear scar along the
rib line.
Decortication — An open posterolateral thoracotomy
and excision of the thick fibrous pleural rind with
evacuation of pyogenic material. This is a longer and
more complicated procedure than minithoracotomy
and leaves a larger linear scar along the rib lineOpen thoracotomy indications
• Late presenting empyema with significant pleural fibrous rind
• Complex empyema and
• Chronic empyema
Fraga JC, Kim P. Surgical treatment of parapneumonic plearl effusion and its
complications. J Pediatr 2002;78(Suppl 2):161–73. [

36. Treatment failure and complications
 Persistent fever - incorrect antibiotic choice or failure of the
antibiotics to penetrate the infected lung tissue or cavity.
 Observe pattern of fever – if improving persist with the
chosen treatment regimen
 Consider lung necrosis and inflammation
 Additionally in these circumstances, a decrease in white blood
cells and C-reactive protein is reassuring.
 Antibiotics recommended for 5 days after child becomes
afebrile followed by oral antibiotics

37. Other complications
 Persistent lobar collapse - unusual . An indication for
bronchoscopy to exclude a foreign body.
 Cavitary necrosis, necrotising pneumonia and
pneumatocoeles may be present on CT scans and are often
a complication of empyema
 Necrotising pneumonia may result in a prolonged hospital –
outcome excellent
 Lung abscess.
 Bronchopleural fistula occurs occasionally following the
insertion of a chest drain or surgery for the treatment of
empyema due to the fragility of lung parenchyma, which leads
to a persistent air leak.
 In these circumstances negative suction on the chest drain is
best avoided to improve the chances of tissue healing.
 Very occasionally surgical intervention is required to repair the
fistula.

38. OUTPATIENT FOLLOW-UP
 Follow up until symptomatic resolution and chest X
ray has returned to near nomal ( BTS )
 The chest radiograph returns to normal in the
majority of children (60–83%) by 3 months, in over
90% by 6 months, and in all by 18 months.
( Chan PW, Crawford O, Wallis C, et al. Treatment of pleural empyema. J Pediatr Child Health
2000;36:375–7 )
Immunodeficiency or cystic fibrosis evaluation - History of recurrent
bacterial infections or poor growth
Cystic fibrosis – esp in S. aureus or Pseudomonas aeruginosa infection

39. TSANZ guidelines

41. Summary
 Antero-posterior/posterior-anterior chest X-ray -
performed in all children in suspected empyma .
There is no need for a routine lateral film.
 Ultrasound – performed in all empyema
 Routine pre-operative CT should not be performed
and should be reserved for complicated cases where
children have failed to respond to treatment or if
there is concern that there is other pathology such
as a tumour.
Paediatric Empyema Thoracis: Recommendations for Management -
Position statement from the Thoracic Society of Australia and New
Zealand.

42. Summary
 High dose antibiotic therapy via the intravenous
route to ensure pleural penetration.
 Appropriate antibiotics should be used to cover at
least Streptococcus pneumonia and Staphylococcus
aureus.
 Moderate to large effusions require drainage.
 Chest drainage alone is not recommended and the
intervention of choice is either percutaneous small
bore drainage with urokinase or VATS
 Oral antibiotics should be given for between 1 and
6 weeks duration following discharge.Final outcome is almost always excellent in children